What’s next for IBS?
On Saturday afternoon at the King’s Hall, Ilkley, Professor Jim Al-Khalili, presenter of The Life Scientific on Radio 4, took us on a voyage into the future. ‘What scientific innovations will become part of our lives in the next thirty years?’ he asked his audience. The answer and the main focus of his talk ‘was artificial intelligence’. He predicted that in the next thirty years most of the jobs in the home and at work will be taken over by computers. Our computerised fridge will alert us when we are running out of certain foods and contact the supermarket to deliver them; our computerised clothes will connect to the washing machine and arrange for them to be washed; maybe even our physiology will be monitored by implanted chips, which will contact the pharmacy for medication. We will have driverless cars, driverless aeroplanes, driverless trains; walk in stores will be phased out; cinemas, theatres, concerts may be a distant memory; everything will be done on line using our smart phones and tablets; even work as we know it will become redundant; life would become electronic.
Many of these predictions are happening already. I thank my lucky stars I will not be around to witness their possible fruition. Al-Khalili asserted that there was no reason why the exponential advance in knowledge that has occurred over the last 70 years, would not continue for the next 50. No doubt the Romans could have declared the same 2000 years ago, but it all came to an untidy end. Advances require time and political stability. In the ‘western world’, we have lived without war or major catastrophe for over seventy years; the whole of my life. It has been a period of unprecedented growth.
But any study of history will show that civilisations do not advance inexorably, they can also retreat. Running parallel with the excitement of innovation is the risk of catastrophe. By 2030 we will need 30% more energy, food and water. At the same time, the climate is warming up at a rate that seems faster than predicted, at least in the northern hemisphere. Floods, hurricanes, droughts and earthquakes are occurring with ever increasing frequency, military conflicts rage at several hotspots around the world, people are on the move, fleeing tyranny and destruction, economic collapse and global war is looking ever more likely. Our way of life, with all of the amazing innovations in communication, is looking increasingly vulnerable. One targeted nuclear strike, a series of malignant computer viruses or a catastrophic energy failure and the world wide web of communication could cease. The world, as we know it, could be plunged into chaos.
Notwithstanding the risk of catastrophe, will we be able to come to terms with the advances in artificial intelligence? Will we resist the loss of agency? Will we have the political wisdom to control the ethical implications of scientific discovery? We have managed to prevent nuclear conflict – just, but have not succeeded in halting nuclear proliferation. Some scientists such as Jennifer Doudna are calling for a moratorium on research on genetic engineering so we have time to debate and consider possible eugenic implications. On a personal level, how many of us would want to inhabit a world, taken over by computers? As work becomes redundant and electronic devices are capturing more of our attention, how would society regulate itself?
People have always tended to take an apocalyptic perspective on scientific advance. In the 1860s, people were complaining about the sheer volume of traffic on London streets, the speed of rail travel and the mechanisation of farming. 100 years later, it was ‘the bomb’ and erosion of any intellectual thought by television. Now it is climate change and social media.
The future for IBS
It’s the medical advances that tend to affect us the most. Will infectious illness, genetic illnesses and cancer be conquered in the next 30 years? How will medicine be practiced then? Will some illnesses have vanished by then? What new diseases will arises? Will we be facing new pandemics? And what about those illnesses, like IBS, that are still poorly understood? Will we even have an illness called IBS by then? I think the best way to approach this is to consider what are currently regarded as recent advances in IBS and extrapolate from these.
Culturing the Gut
Arguably the most exciting has been the explosion in our understanding of the colonic microbiome and its impact on the health of the gut and all other organs of the body including the brain. In a few diseases, such as Crohn’s Disease, Parkinson’s Disease and obesity, particular organisms have been implicated. There is some evidence for the involvement of methane producing species in constipation. Nevertheless, IBS tends to be associated with a depleted and unstable microbiome though whether that is the cause of IBS or the result of the illness or a depleted diet is not clear.
The identification of the large number of foods that contain poorly absorbed carbohydrates (FODMAPs) has emphasised the importance of bacterial fermentation in the generation of IBS symptoms. In 2006, Dr Peter Gibson’s team at Monash introduced the Low FODMAP diet, but in recent years, but its popularity is challenged by its complexity, the variability in symptomatic responses and the reductions in beneficial bacteroides spp. In the next ten years, the nutritionally deplete low FODMAP diet may well become redundant as scientists we identify the specific combinations of foods and micro-organisms that generate symptoms and devise customised diets to combat these.
Looking after the gut may become rather like looking after a garden, and like gardeners, we may be able to learn how to culture and control the microbes in our gut by combinations of diet and life style. Smart pills (see image above) have already been produced to ‘sniff out’ the volatile chemicals produced in the colon. We will learn much more about the interaction between micro-organisms in the gut, how they trigger immune responses, how they can generate the transmitters responsible for controlling gut and brain responses and the effects of viruses on bacterial metabolism. We will understand and be able to influence the epigenetic factors that turn on and off different metabolic pathways. It may even be possible to genetically engineer the microbes in the gut to produce specific enzymes and neurotransmitters.
The blanket prescription of probiotics, many of which cannot establish themselves in the colon may well give way to a new generations of effective synbiotics or even symbiotics, which can seed the gut and survive. The concept of psychobiotics, able to influence IBS by altering mood and behaviour is ripe for development. Drugs may also become redundant as we learn how to grow micro-organisms to produce specific transmitters where they are needed. Viruses might also be used to alter bacterial metabolism and epithelial responses.
IBS – the visceral expression of dysphoria
IBS overlaps with many other illnesses and symptoms. There is particular overlap with anxiety and depression. Stressful events can precipitate episodes of IBS. Patients with particularly stressful life styles or who are struggling to cope with particularly stressful situations are often afflicted afflicted with IBS. There is evidence that life trauma can initiate a predisposition to suffer symptoms of IBS in response to stressful situations. in recent years there have been enormous advances in our understanding of the neuroscience of stress and trauma and its effects on the body. There are no signs these are slowing down. Insights from neuroscience may well cause us to re-evaluate many cases of IBS as ‘the visceral expression of what has happened’. By the same token, headache, backache, fatigue, muscle pain, chest pain, shortness of breath and many other physical symptoms may also be regarded as bodily expressions of the same overarching state of dysphoria. This questions what determines the particular bodily expression in any individual. What is the role of local factors such as immune reactions to specific bacteria, gene expression prompted by certain chemical triggers, the somatic memory of previous illness and injury or just what the symptoms represent to the individual?
Increasing understanding of the neuroscience of stress and trauma may well prompt the development of new ways of restoring a sense of control and well-being. Hypnotherapy, EMDR, stimulation of the vagal nerves in the neck have all been shown to reduce somatic symptoms. In the future, we may well be able to exert more control over our emotional reactions, perhaps by the use of innovative ‘apps’ on our electronic ‘devices’, or non invasive ways of modulating the activity of discrete centres in the brain stem.
Self Care
IBS occupies a disproportionate amount of medical resources and time. With increasing pressure on health services and limited resources, more effort will need to be devoted to facilitating self help. During the time, I was associated with the charity, The IBS Network developed a comprehensive IBS Self Care Programme, which included a symptom tracker, frequently asked questions, on-line ask-the-expert service, and a telephone helpline. This could go further and become more interactive using apps for smart phones and tablets. These might include a much more comprehensive response to questions using voice recognition technology, an improved symptom tracker with on-line advice, access to drugs and tests on-line and tutorials on self hypnosis, mindfulness, dietary and life style advice. Such developments are too urgent for small charities like The IBS Network to fund, and it is inappropriate to seek funding from companies, who wish to sell their products for IBS. The British National Health Service is in crisis. Ministers need to think outside the box. The investment of funds to develop self management apps for the third of the population with unexplained illnesses might save billions and direct resources to where medical resources are more urgently needed.
Connectivity
IBS currently affects between 10 and 20% of people living in ‘westernised’ countries, but opinion is divided as to whether it is getting commoner. Part of the difficulty is that definitions of IBS keep changing with every new revision of The Rome Criteria. If, however, we take a broader vision and include all unexplained symptoms or long term illnesses, the indications are that these have more than doubled in the last fifty years and now affect over a third of the population. So has the exponential growth in technological advance been accompanied by an exponential increase in unexplained illness? Or might it just seem so? Were these illnesses always there, but in another guise and regarded more as part of life? So will IBS increase as time goes on? If a depleted and unstable microbiome and the a high frequency of life trauma are implicated in the pathogenesis of IBS, then the indications are IBS will become more common. Social and familial connectivity are crucial to our happiness and well-being. Rapid technological advances of the last 25 years have eroded social connections. People spend much more time interacting with their tablets and smart phones than talking and thinking together. If social isolation is a major component of IBS, then our technological advances may well make it worse.
The Sensitive Gut 
IBS will always be around, especially if we keep eating crap late at night
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